RH in Bhutan

The small, Switzerland-sized, Himalayan nation of Bhutan has only recently emerged from the Middle Ages and from its Middle-Ages-level reproductive health problems.

Fifty years ago in Bhutan, there were no schools, no currency, no mail, no roads and no health care beyond what traditional healers provided. There were no clinics, hospitals, doctors or nurses. There were no modern contraceptives. There were no statistics on either health or demography. The size of the population was unknown, as was life expectancy, and infant and maternal mortality. There was a tradition of traditional medicine, although the traditional medicine practitioners I spoke to professed not to know which herbs were and are currently used for pregnancy prevention and pregnancy termination.

From a standing start in 1960, Bhutan has developed, so that now there is universal primary education (classes are taught in English, except those in Bhutanese history and language), as well as a free health care system of hospitals and rural health clinics that reaches almost the entire population. It would reach all of it, but the rudimentary road system does not come close to covering the nation, and the vast majority of the populace has to walk or rely on overcrowded and sporadic busses to reach nearby towns.

Statistical gathering remains less than scientific. For instance, the UN reports that Bhutan has a population of 2.3 million, whereas the Bhutanese report a population of approximately 700,000. See the UN State of the World Population Report for 2007. http://www.unfpa.org/swp/2007/english/notes/indicators.html

Therefore, any statistics that are reported should be taken with a grain of salt. According to the UN, life expectancy is about 63 for males and 66 for females; infant mortality is 48 per 1000 live births (it was 102 in 1984) and the maternal mortality ratio is 420 (it was 770 in 1984), both about 20% lower than neighboring India; contraceptive coverage is around 20%; the TFR is 3.9 (it was 4.7 in 2000); about a quarter of births are attended by a skilled birth attendant. Childhood vaccinations are almost universal, and as a result of reduced infant mortality and increased life expectancy, the population has been growing rapidly (at 2.2% annually the UN reports; it was at 3.1% in the mid-1990’s), yet labor is imported for road and construction work from Nepal and India.

There is not the sex ratio imbalance at birth that is seen in India and China. In schools there is a dominance of females in the later grades, after many boys are sent to monasteries or drop out to work the family farm (about 10% of the male population are monks and 90% of the population work in agriculture or forestry). In one school I visited, in the 12 year old class, there were 16 girls and 7 boys. The society operates as a matriarchy. The eldest daughter inherits the family farm, and her husband comes to live with her, and with her parents until they retire after age 50 or so to a community monastery to pray and meditate.

Modern contraceptives are widely available, with the government health clinics offering free oral contraceptives, IUD’s, Depo-Provera and condoms, as well as male and female sterilization. Oral contraceptives are also sold in pharmacies at $2 per cycle and condoms are sold for $1 and $2 depending on the brand. Condoms are also distributed for free at various non-health locations in cities and towns. Still, as noted above, there are many couples not using contraception, due to a combination of a desire for large families and lack of access.

A visit to a rural health clinic gave some perspective on all these statistics. The following statistics (for 2007) were posted on the wall of the doctor’s office. This particular clinic covered an area with 243 households and 1257 inhabitants (about 5 persons per household), with slightly more females than males (641 to 616). There were 286 females of reproductive age between the ages of 15 and 49. There were 16 infants less than 1 year old and 91 children less than 5.

There were no reported infant deaths, child deaths or maternal deaths in 2007. The doctor has a network of “informants” around the village and as soon as it is known that a woman is pregnant, this fact is reported to him, and he makes a visit to the home, where he talks about prenatal care and sees to it that the woman has at least 4 prenatal appointments. When delivery time approaches, he arranges for the woman, if she can, to go to the regional hospital a week before her delivery date, accompanied by a relative who has her same blood type in case a transfusion is needed (anemia being a major complication in pregnancy). Naturally this is not possible in every case, and in 2007, of 18 pregnancies about half were attended at home and half delivered at the hospital.

Of the 286 females of reproductive age, there were 6 IUD users, 89 Depo users and 9 pill users. There were no sterilizations performed. Condoms are kept in a box by the door that woman and men can access without entering the clinic. The balance of the women of reproductive age presumably were using condoms, were not sexually active or were, or were trying to get, pregnant.

There are HIV/AIDS awareness signs in the clinic and along the roads of the town. Sex Ed begins in secondary school, though there is health and hygiene instruction in primary school, where teachers are required to inspect the children weekly to be sure that their uniforms and fingernails are clean, and that they have a handkerchief pinned to their uniform if their nose is running.

There is testing in the clinics for sexually transmitted diseases, and the rates are unofficially reported to be high. Bhutan is not a puritanical society, although public displays of affection are frowned upon, and couples pair and un-pair with some regularity and often get married only when the female becomes pregnant.

The abortion rate is unknown. I was told that abortion was against Buddhist ethics and was illegal except to save the life of the mother. Naturally, there is a problem of unsafe abortion. In a 1999 survey, of 654 obstetric complications, 71, or 14%, were due to septic abortion. In the clinic I visited, the physician did not report any septic abortions. Bhutan is surrounded by nations that have decriminalized abortion: India and China, and Nepal, although Nepal does not technically border Bhutan. One can hope that given the difficulties of travel for most citizens, Bhutan does not think it can rely on abortion tourism (or self induced abortion) to be the only alternatives for its women for pregnancy termination.

Despite its reputation as a Shangri-La, Bhutan has a domestic violence problem. Recently, one of the Queens founded an organization called RENEW to provide shelter and counseling for abused woman. It is located in a modern facility in the capital. Additionally, RENEW is constructing a residential safe house facility for women and their children to provided temporary housing until the woman can get divorced and resettled in society. They do a wonderful job, but it was sobering that such an organization needs to exist in this otherwise peaceful nation. See http://www.renew.org.bt/

Since Bhutan has a military force of only 4,000 (the Indian Army picks up the slack), it can, and does, spend a large proportion of its budget, approximately 15%, on health care. With improving infant and maternal mortality, the results are plain and commendable. One can hope that progress continues.

Alexander C. Sanger, the grandson of Margaret Sanger, who founded the birth control movement over eighty years ago, is currently Chair of the International Planned Parenthood Council.

Mr. Sanger previously served as the President of Planned Parenthood of New York City (PPNYC) and its international arm, The Margaret Sanger Center International (MSCI) for ten years from 1991 - 2000.
Mr. Sanger speaks around the country and the world and has served as a Goodwill Ambassador for the United Nations Population Fund.